Care Coordination RN Sr. (Weekdays)

Wellstar Health System•Austell, GA

About The Position

The Care Coordination RN Sr. coordinates care facilitation, care progression, and transitional care planning for complex cases during a patient's acute hospital admission. The role partners with physicians and interdisciplinary care teams to support appropriate, efficient treatment plans, manage length of stay, use resources effectively, and plan for post-discharge care. The RN Sr. also serves as an expert resource and consultant to other team members on care progression and patient needs, and may help orient and precept new employees and mentor less senior staff and student interns. Responsibilities include assessing patients' clinical, psychosocial, functional, and resource needs; coordinating care progression and discharge planning with patients, families, physicians, care teams, and payers; identifying and addressing barriers and delays; arranging post-acute referrals; documenting care and discharge planning in the medical record; and contributing to professional development and departmental goals. The role is a weekday day shift position. The posting states “No Patient Care” under Patient Care Options.

Requirements

At least 3 years of experience as a staff nurse in an acute care hospital setting.
At least 2 years of experience as a case manager in a hospital setting or payer-based model, with case management competency and the ability to guide care teams through complex discussions.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Self-directed, with the ability to function under stress, handle change, and work in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of applicable local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, and patients and families across the continuum of care.
Required upon hire: Registered Nurse license (single-state or RN multi-state compact) and Basic Life Support certification (or BLS Instructor certification).

Nice To Haves

Certified Case Manager certification upon hire.
Accredited Case Manager certification upon hire.

Responsibilities

Assess patients' psychosocial risk factors, available discharge resources, insurance, and coverage requirements in collaboration with patients, families, physicians, care teams, PAS, financial counselors, and utilization management nurses.
Collaborate routinely with physicians and care teams to support timely, efficient patient management and care progression.
Identify diagnostic or treatment delays and obstacles, discuss inpatient medical necessity with physicians, and work to resolve or escalate discharge barriers.
Manage discharge planning for assigned patients, including assessing needs, developing individualized plans, documenting barriers, and arranging resources and post-acute referrals.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend an appropriate level of care transition.
Maintain consensus on discharge plans among patients, families, physicians, care teams, and payers, while considering cultural and religious beliefs.
Refer appropriate cases for social work intervention according to departmental protocol.
Complete and maintain clear, timely, accurate clinical and psychosocial documentation in the medical record, including services arranged or delivered and interactions related to discharge planning.
Track avoidable days and report trends that contribute to undesired outcomes.
Assist leadership with precepting new hires and mentor new or less senior employees and student interns.
Complete required competency assessments and education, and support department goals.
Perform other duties as assigned and comply with Wellstar policies, standards of work, and code of conduct.